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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> n D/' OFFICE USE ONLY <br /> Date <br /> FA, REA <br /> �ZnS7'Cn REF # <br /> To: San Joaquin County CR # <br /> Department of Public Works ATE <br /> -- TO DRIVEWAYS: <br /> (Applicant Name) <br /> QUAD <br /> TYPE <br /> (Mailing Address) <br /> FORMS " <br /> ��. NOTE" <br /> (City, State, Zip Code) <br /> 2 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plaits may be submitted) <br /> I <br /> p"M: �OL�-SD�12 <br /> The undersigned her applies for permission to excavate, construct and/or <br /> ide of <br /> otherwise encroach on. County Highway Right-of-Way on the -- - <br /> approximately feet/n�ie <br /> * by p rforming he <br /> an of <br /> following work_ (description f work) : <br /> for approximately <br /> Work ill commence on or about <br /> O <br /> days- I <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> to represent the owner and agree to do the work describedanbjecteton <br /> qualifiedP <br /> regulations of San Joaquin County and J <br /> accordance with the .rules, g <br /> Whr <br /> -) Date <br /> tP <br /> e of Applicant - Title <br /> RETURN PERMITS TO: <br /> =L (6/00) \� P"E <br /> ..M S <br /> JOB PSM DESK- BLD 1 <br /> Low <br />